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O. Reg. 546/05: Statutory Accident Benefits Schedule - Accidents on or after November 1, 1996

filed October 28, 2005 under Insurance Act, R.S.O. 1990, c. I.8

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ontario regulation 546/05

made under the

insurance act

Made: October 26, 2005
Filed: October 28, 2005
Printed in The Ontario Gazette: November 12, 2005

Amending O. Reg. 403/96

(Statutory Accident Benefits Schedule — Accidents on or after November 1, 1996)

1. (1) The definition of “designated assessment centre” in subsection 2 (1) of Ontario Regulation 403/96 is revoked and the following substituted:

“designated assessment centre” means an assessment centre that was designated before January 1, 2005 under section 52 as that section read on February 28, 2006; (“centre d’évaluation désigné”)

(2) Subsection 2 (1) of the Regulation is amended by adding the following definitions:

“assessment of attendant care needs” means a written assessment of attendant care needs that satisfies the requirements of section 39; (“évaluation des besoins en soins auxiliaires”)

“disability certificate” means, in respect of a person, a certificate from a health practitioner of the person’s choice that states the cause and nature of the person’s impairment and contains an estimate of the duration of the disability in respect of which the person is making or has made a claim for a benefit set out in this Regulation; (“certificat d’invalidité”)

“social worker” means a member of the Ontario College of Social Workers and Social Service Workers who holds a certificate of registration for social work under the Social Work and Social Service Work Act, 1998; (“travailleur social”)

2. Section 20 of the Regulation is amended by adding the following subsections:

(2.1) The insurer may require a person who claims or is receiving benefits under this section to furnish a disability certificate as often as is reasonably necessary.

(2.2) If an insurer requires a disability certificate, the person shall furnish a new disability certificate, completed as of a date after the date of the insurer’s request, within 15 business days after receiving the insurer’s request.

(2.3) If the person fails to comply with subsection (2.2), no amount is payable for lost educational expenses until the person furnishes the completed disability certificate.

3. (1) Subsections 24 (1) and (1.1) of the Regulation are revoked and the following substituted:

(1) The insurer shall pay the following expenses incurred by or on behalf of an insured person:

1. Reasonable fees charged by a health practitioner for preparing a disability certificate required under section 20, 35 or 37.

2. Fees charged in accordance with a Pre-approved Framework Guideline by a health practitioner for preparing a treatment confirmation form for the purposes of section 37.1.

3. Fees charged in accordance with a Pre-approved Framework Guideline by a member of a health profession for conducting an assessment or examination and preparing a report for the purposes of section 37.1.

4. Reasonable fees charged by a health practitioner for reviewing a treatment plan under section 38, and for approving it if appropriate.

5. Reasonable fees charged by a member of a health profession or a social worker for preparing an application under section 38.2 for approval of an assessment or examination.

6. Reasonable fees charged by a member of a health profession for preparing an assessment of attendant care needs under section 39.

7. Reasonable fees charged by a health practitioner for preparing an application under section 40 for a determination of whether the insured person has sustained a catastrophic impairment.

8. Fees charged for a designated assessment of the insured person.

9. Subject to subsection 24.1 (2), reasonable fees charged by a member of a health profession for consulting with a person who is conducting or has conducted an examination of the insured person under section 42, if the conditions set out in subsection 24.1 (1) are satisfied.

10. Reasonable fees and expenses in accordance with section 42.1 that are charged for an assessment or examination of the insured person and the preparation of a report of the assessment or examination.

11. Reasonable fees, other than fees referred to in any of paragraphs 1 to 10, that are charged by a member of a health profession or a social worker for conducting an assessment or examination and preparing a report if the assessment or examination is reasonably required in connection with a benefit that is claimed or in connection with the preparation of a treatment plan, disability certificate, assessment of attendant care needs or application for the determination of a catastrophic impairment, and

i. the assessment or examination relates to ancillary goods or services described in section 37.2 and is contemplated by a treatment confirmation form submitted in accordance with section 37.1,

ii. the insured person applied for approval of the assessment or examination either in a treatment plan submitted under section 38 or by way of a separate application submitted under section 38.2, or

iii. the insurer approved the expense or the approval of the insurer is not required by reason of subsection (1.2).

(1.1) Despite subsection (1), an insurer is not required to pay for an assessment or examination referred to in subparagraph 11 ii of subsection (1) if the expense for the assessment or examination is incurred,

(a) before the insurer approves the expense;

(b) before the insurer receives the report of an examination under section 42, if the insurer requires the insured person to be examined under that section; or

(c) before the insurer receives the report of a designated assessment, in the case of an application for approval of an assessment or examination under section 38.2, if the insured person is required to undergo a designated assessment.

(2) Paragraphs 2, 3 and 4 of subsection 24 (1.2) of the Regulation are revoked and the following substituted:

2. Not more than three assessments or examinations for the purposes of preparing a treatment plan under section 38 if not more than one assessment or examination is done by the same person and the cost of each assessment or examination does not exceed $200.

3. An assessment or examination for the purposes of preparing a disability certificate under section 20, 35 or 37 if the cost of the assessment or examination does not exceed $200.

(3) Paragraph 8 of subsection 24 (1.2) of the Regulation is revoked.

(4) Subsections 24 (1.3), (1.4) and (1.5) of the Regulation are revoked.

4. The Regulation is amended by adding the following section:

24.1 (1) The following conditions must be satisfied for the purposes of paragraph 9 of subsection 24 (1):

1. The consulting fees must be charged by one of the following persons:

i. the health practitioner who prepared the disability certificate, if the examination relates to a claim in respect of which a disability certificate is required under this Regulation,

ii. the health practitioner who approved the treatment plan, if the examination relates to a claim for medical or rehabilitation benefits,

iii. the member of the health profession who prepared the assessment of attendant care needs, if the examination relates to an application under section 39, or

iv. the health practitioner who prepared the application, if the examination relates to an application under section 40 to assist the insurer determine whether the insured person has sustained a catastrophic impairment.

2. The consultation must be arranged by mutual agreement of the person who is conducting or has conducted the examination under section 42 and the health practitioner or member of the health profession involved in the consultation.

3. The fees must be reasonable and, subject to subsection (2), shall not exceed the amount ordinarily charged for a 30 minute professional consultation by telephone.

(2) If under a Guideline a maximum rate or amount for expenses is established that applies to the claim with respect to which the examination under section 42 and consultation relate and the payment of the fees for the consultation would result in the expenses exceeding this maximum rate or amount, only the portion of the fees for the consultation that would not result in the expenses for the claim exceeding the maximum rate or amount shall be paid.

5. (1) Subsection 32 (3.1) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

(2) Subsection 32 (6) of the Regulation is revoked and the following substituted:

(6) Despite any shorter time limit in this Regulation, if a person fails without a reasonable explanation to notify an insurer under subsection (1) within the time required under subsection (1.1), the insurer may delay determining if the person is entitled to a benefit under section 35, 38, 39 or 41 and may delay paying the benefit until the later of,

(a) 45 days after the day the insurer receives the person’s application; or

(b) 10 business days after the day the person complies with any request made by the insurer under subsection 33 (1) or (1.1).

6. The Regulation is amended by adding the following section:

Pre-claim Examination

32.1 (1) This section applies if,

(a) as a result of an accident, an insured person was admitted to a hospital or long-term care facility and is still in the hospital or facility or was discharged within the previous three days;

(b) the insured person may be entitled to medical benefits for an assistive device referred to in clause 14 (2) (f), rehabilitation benefits under clause 15 (5) (i) or attendant care benefits under section 16; and

(c) no application has yet been made for a benefit to which the insured person may be entitled as a result of the accident.

(2) At the insured person’s request or with his or her consent, the insurer may arrange for the insured person to be examined at the insurer’s expense for the purposes of assisting the insurer in determining if the insured person is entitled to receive a benefit described in clause (1) (b) that would assist the insured person after his or her discharge from the hospital or long-term care facility.

(3) An examination under this section shall be conducted by one or more members of one or more health professions who are chosen by the insurer.

(4) The insurer shall notify the insured person of the name of the person or persons who will conduct the examination and the day, time and place for the examination.

(5) The insurer shall, before the examination, obtain the written and signed consent of the insured person for the examination.

(6) The person or persons who conducted the examination shall, within five business days after conducting the examination, prepare a written report and, if applicable, an assessment of attendant care needs and provide a copy to,

(a) the insurer;

(b) the insured person; and

(c) if the insured person has a health practitioner, that health practitioner.

(7) An examination under this section is voluntary and any failure or refusal of an insured person to consent to an examination under this section does not affect any rights the insured person may have to apply for or receive benefits as a result of the accident.

(8) The report of an examination under this section shall not be relied on by an insurer in making a determination that an insured person is not entitled to a benefit under this Regulation. 

7. Subsection 33 (1) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

8. Section 34 of the Regulation is revoked.

9. Section 35 of the Regulation is revoked and the following substituted:

Income Replacement, Non-earner or Caregiver Benefits and Housekeeping or Home Maintenance Expenses

35. (1) In this section and section 37,

“specified benefit” means an income replacement benefit, non-earner benefit, caregiver benefit or a payment for housekeeping or home maintenance services under section 22.

(2) An insured person who applies for a specified benefit shall submit with the application a disability certificate completed no earlier than 10 business days before the date the application is submitted.

(3) Within 10 business days after the insurer receives the application and completed disability certificate, the insurer shall, 

(a) pay the specified benefit;

(b) send a request to the insured person under subsection 33 (1) or (1.1); or

(c) notify the insured person that the insurer requires the insured person to be examined under section 42.

(4) If the insurer sends a request to the insured person under subsection 33 (1) or (1.1), the insurer shall, within 10 business days after the insured person complies with the request,

(a) pay the specified benefit; or

(b) notify the insured person that the insurer requires the insured person to be examined under section 42.

(5) Every income replacement benefit, non-earner benefit or caregiver benefit shall be paid at least once every second week, subject to any prepayment of the benefit by the insurer.

(6) An insurer may make a determination that an insured person is not entitled to a specified benefit if,

(a) the insured person failed or refused to submit the completed disability certificate required under subsection (2);

(b) the insurer has received the report of the examination under section 42, if the insurer has required the insured person to be examined under that section;

(c) the insurer is entitled under subsection (10) to refuse to pay the specified benefit; or

(d) the insured person is not entitled to the specified benefit for reasons unrelated to whether the insured person has an impairment that entitles the insured person to the specified benefit.

(7) If an insurer determines that an insured person is not entitled to receive a specified benefit by reason of clause (6) (a), (c) or (d), the insurer shall give the insured person a copy of its determination,

(a) within 10 business days after receiving the application, if the insured person is not entitled to the specified benefit by reason of clause (6) (a) or (d); or

(b) within 10 business days after the insured person failed or refused to comply with subsection 42 (10), if the insured person is not entitled to the specified benefit by reason of clause (6) (c).

(8) Within five business days after receiving the report of the examination of the insured person under section 42, the insurer shall give a copy of the report and of the insurer’s determination to the insured person and to the health practitioner who completed the disability certificate submitted with the application.

(9) The insurer shall set out in its determination the specified benefits and expenses the insurer agrees to pay, the specified benefits and expenses the insurer refuses to pay and the reasons for the insurer’s decision.

(10) If the insured person fails or refuses to comply with subsection 42 (10), the insurer,

(a) may make a determination that the insured person is not entitled to any specified benefit; and

(b) may refuse to pay specified benefits relating to the period after the insured person failed or refused to comply with subsection 42 (10) and before the insured person submits to the examination or provides the material required by that subsection.

(11) If the insured person subsequently complies with subsection 42 (10), the insurer shall,

(a) reconsider the application and make a new determination under this section; and

(b) pay all amounts, if any, that were withheld during the period of non-compliance, if the insurer determines that the insured person is entitled to any specified benefits and the insured person provides not later than the 10th business day after the failure or refusal to comply, or as soon as practicable after that day, a reasonable explanation for not complying with subsection 42 (10). 

(12) If the insurer determines after receipt of the report under section 42 that the insured person is entitled to a specified benefit, the insurer shall pay the specified benefit within 10 business days after receiving the report. 

(13) If an insured person fails to submit a completed disability certificate with his or her application for a specified benefit, no specified benefits are payable for the period after the day the insurer receives the application and before the day the insurer receives the completed disability certificate.

(14) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the claim by the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed, the insurer shall pay all specified benefits to which the application relates for the period commencing on that day and ending on the day the insurer gives the insured person the report or determination.

10. Subsection 36 (3) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

11. Section 37 of the Regulation is revoked and the following substituted:

Determination of Continuing Entitlement to Specified Benefits

37. (1) If an insurer wishes to determine if an insured person is still entitled to a specified benefit, the insurer,

(a) shall request that the insured person submit within 15 business days a new disability certificate completed as of a date on or after the date of the request; and

(b) may notify the insured person that the insurer requires the insured person to be examined under section 42.

(2) An insurer shall not discontinue paying a specified benefit to an insured person unless,

(a) the insured person fails or refuses to submit a completed disability certificate as required under clause (1) (a);

(b) the insurer has received the report of the examination under section 42, if the insurer required the insured person to be examined under that section;

(c) the insurer is entitled under subsection (7) to refuse to pay the specified benefit;

(d) the insured person has resumed his or her pre-accident employment duties;

(e) the insurer is no longer required to pay the specified benefit by reason of clause 5 (2) (d) or (e), subsection 22 (3) or 33 (2) or section 55 or 56; or

(f) the insured person is not entitled to the specified benefit for a reason unrelated to whether he or she has an impairment that entitles the insured person to receive the specified benefit.

(3) If an insured person fails to submit a completed disability certificate as required under clause (1) (a), no specified benefits are payable for the period commencing the 15th business day after the day the insured person received the insurer’s request and ending, if the insured person subsequently submits a completed disability certificate, the day the insurer receives the completed disability certificate.

(4) If the insurer determines that the person is not entitled to receive any specified benefit by reason of clause (2) (a), (c), (d), (e) or (f), the insurer shall give to the insured person a copy of its determination.

(5) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination with respect to the specified benefit to the insured person and to the health practitioner who completed the disability certificate.

(6) The determination of the insurer shall specify,

(a) the specified benefits and expenses the insurer agrees to pay;

(b) the specified benefits and expenses the insurer refuses to pay;

(c) the reasons for the insurer’s decision; and

(d) if the insurer determines that the insured person is not entitled to a specified benefit, the date that payment of the benefit will be stopped.

(7) If the insured person fails or refuses to comply with subsection 42 (10), the insurer may,

(a) make a determination that the insured person is no longer entitled to the specified benefit; and

(b) despite subsection (9), refuse to pay specified benefits relating to the period after the insured person failed or refused to comply with subsection 42 (10) and before the insured person submits to the examination or provides the material required under that subsection.

(8) If the insured person subsequently complies with subsection 42 (10), the insurer shall,

(a) reconsider the insured person’s entitlement to the specified benefit and make a determination;

(b) subject to the insurer’s determination, resume payment of the specified benefit; and

(c) pay all amounts, if any, that were withheld during the period of non-compliance if the insured person provides not later than the 10th business day after the failure or refusal to comply, or as soon as practicable after that day, a reasonable explanation for not complying with subsection 42 (10).

(9) If an insurer requires an insured person to be examined under section 42 and determines that the insured person is not entitled to a specified benefit, the insurer shall not stop payment of the specified benefit unless it has provided to the insured person a copy of the report of the examination and its determination under this section.

12. (1) Subsection 37.1 (8) of the Regulation is amended by striking out “or” at the end of clause (a), by adding “or” at the end of clause (b) and by adding the following clause:

(c) that the insurer is required under subsection 37.2 (9) to pay for and that have been provided.

(2) Subsection 37.1 (13) of the Regulation is revoked.

13. Subsections 37.2 (2), (3), (4) and (5) of the Regulation are revoked and the following substituted:

(2) If a treatment confirmation form under section 37.1 includes a claim for ancillary goods or services, the insurer shall,

(a) include in the notice required under subsection 37.1 (5) a statement of which ancillary goods and services, if any, the insurer agrees to pay for; and

(b) notify the insured person that the insurer requires the insured person to be examined under section 42, if the insurer has not agreed to pay for all of the ancillary goods and services included in the claim.

(3) A notice referred to in clause (2) (b) must be given to the insured person within five business days after the day the insurer receives the treatment confirmation form.

(4) If the insurer fails to comply with the requirements of subsection 37.1 (5) or subsection (3) of this section within the time required under those subsections, the insurer shall pay for all ancillary goods and services delivered under the treatment confirmation form.

(5) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination with respect to payment for the ancillary goods and services to the insured person and the health practitioner who prepared the treatment confirmation form.

(6) The determination of the insurer shall specify the ancillary goods and services the insurer agrees to pay for, the ancillary goods and services the insurer refuses to pay for and the reasons for the insurer’s decision.

(7) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may make a determination that the insured person is not entitled to payment for the ancillary goods and services to which the examination relates.

(8) If an insured person subsequently complies with subsection 42 (10), the insurer shall reconsider the insured person’s claim and make a determination under this section.

(9) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the claim by the day determined in the following manner, the insurer shall pay for all ancillary goods and services provided in accordance with the treatment confirmation form:

1. If the attendance of the insured person was not required for the examination under section 42, the day is the 10th business day after the day the material required under subsection 42 (10) was provided.

2. If the attendance of the insured person was required for the examination, the day is the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed.

14. (1) Clause 38 (1) (b) of the Regulation is revoked and the following substituted:

(b) applications for assessments or examinations that are submitted with a treatment plan under subsection (2). 

(2) Subsection 38 (1.1) of the Regulation is revoked and the following substituted:

(1.1) An insurer is not liable to pay any expense in respect of medical benefits or rehabilitation benefits that was incurred before the insured person submits an application for the benefit that satisfies the requirements of subsection (2) unless the expense is for an ambulance or other goods or services provided on an emergency basis not more than five business days after the accident to which the application relates.

(3) Clause 38 (2) (a) of the Regulation is revoked and the following substituted:

(a) a treatment plan that complies with subsection (3), prepared by a member of a health profession or by a social worker; and

(4) Subsection 38 (3) of the Regulation is amended by striking out “the member of a health profession who prepared the plan” in the portion before clause (a) and substituting “the person who prepared the plan”.

(5) Subsection 38 (3.1) of the Regulation is revoked.

(6) Subsection 38 (5) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

(7) Paragraphs 1 and 2 of subsection 38 (8) of the Regulation are revoked and the following substituted:

1. A notice,

i. that discloses any conflict of interest the insurer has relating to the treatment plan,

ii. that describes the goods and services, if any, contemplated by the treatment plan that the insurer agrees to pay for, and

iii. that advises the insured person, if the insurer has not agreed to pay for all goods and services contemplated by the treatment plan, that the insurer requires the insured person to be examined under section 42 relating to the goods and services the insurer has not agreed to pay for.

2. A notice advising the insured person that the insurer,

i. believes that the insured person may have an impairment to which a Pre-approved Framework Guideline applies, and

ii. requires the insured person to be examined under section 42 to assist the insurer in determining if the insured person has an impairment to which a Pre-approved Framework Guideline applies.

(8) Clause 38 (8.1) (a) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

(9) Subparagraph 1 i of subsection 38 (8.2) of the Regulation is revoked and the following substituted:

i. the insurer shall not take the position that the insured person has an impairment to which a Pre-approved Framework Guideline applies, and

(10) Paragraph 2 of subsection 38 (8.2) of the Regulation is revoked and the following substituted:

2. In the case of a notice under paragraph 1 of subsection (8), the insurer shall pay for all goods and services provided under the treatment plan that relate to the period starting on the 11th business day after the day the insurer received the application and ending on the day the insurer gives the notice described in paragraph 1 of subsection (8).

(11) Subsection 38 (9) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

(12) Subsections 38 (12) and (12.1) of the Regulation are revoked.

(13) Subsections 38 (12.2), (12.3), (13), (14), (15) and (18) of the Regulation are revoked and the following substituted:

(12.2) If an insurer gives a notice described in paragraph 2 of subsection (8), the insured person may submit a treatment confirmation form under section 37.1 and, pending the insurer’s determination, may receive goods and services in accordance with the Pre-approved Framework Guideline and such ancillary goods and services as the insurer believes to be appropriate for the insured person’s impairment.

(13) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination to the insured person and to the health practitioner who approved the treatment plan.

(14) The determination of the insurer shall specify,

(a) the goods and services contemplated by the treatment plan that the insurer agrees to pay for, the goods and services the insurer refuses to pay for and the reasons for the insurer’s decision, in the case where the insurer gave a notice referred to in paragraph 1 of subsection (8); or

(b) whether the insurer has determined that the insured person has an impairment to which a Pre-approved Framework Guideline applies and the reasons for the insurer’s decision, in the case where the insurer gave a notice referred to in paragraph 2 of subsection (8).

(15) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may make a determination that the insured person is not entitled to the goods and services contemplated by the treatment plan.

(16) If an insured person subsequently complies with subsection 42 (10), the insurer shall reconsider the insured person’s claim and make a determination under this section.

(17) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the claim by the day determined under subsection (17.1),

(a) the insurer shall pay for all goods and services provided in accordance with the treatment plan during the period commencing on that day and ending on the day the insurer gives the insured person the report or determination; and

(b) the insurer shall not take the position that the insured person has an impairment to which a Pre-approved Framework Guideline applies.

(17.1) For the purposes of subsection (17) the day is determined as follows:

1. If the attendance of the insured person was not required for the examination under section 42, the day is the 10th business day after the day the material required under subsection 42 (10) was provided.

2. If the attendance of the insured person was required for the examination, the day is the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed.

(17.2) An insurer shall pay an expense in respect of medical or rehabilitation benefits that it has agreed to pay or that it is required under this section to pay within 30 days after receiving an invoice for the expense.

(14) Subsection 38 (19) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

15. Subsection 38.1 (4) of the Regulation is revoked and the following substituted:

(4) Every member of a health profession and social worker who refers an insured person to another person to obtain goods or services in respect of which a medical or rehabilitation benefits will be paid by an insurer under this section shall give the insurer and the insured person written notice disclosing any conflict of interest the member of the health profession or social worker has relating to the provision of the goods or services. 

16. (1) The heading before section 38.2 and subsection 38.2 (1) of the Regulation are revoked and the following substituted:

Application for Approval of an Assessment or Examination

(1) This section applies to an application prepared by a member of a health profession or social worker for approval of an assessment or examination of an insured person if the application is not submitted as part of a treatment plan under section 38.

(2) Subsection 38.2 (2) of the Regulation is amended by striking out “the member of a health profession” and substituting “the member of a health profession or social worker”.

(3) Subsections 38.2 (6), (7) and (8) of the Regulation are revoked and the following substituted:

(6) If the insurer has not refused the application under subsection (4), the insurer shall give the insured person and the person who prepared the application a notice,

(a) within two business days after receiving the application if the application is received before March 1, 2006 and the amount to be charged is $180 or less;

(b) within five business days after receiving the application if the application is received before March 1, 2006 and the amount to be charged exceeds $180; or

(c) within three business days after receiving the application, if the application is received on or after March 1, 2006.

(7) The notice under subsection (6) must,

(a) state which assessments or examinations in the application the insurer agrees to pay for;

(b) advise the insured person that the insurer requires the insured person to be examined under section 42, if the insurer has not agreed to pay for all assessments or examinations to which the application relates; and

(c) disclose any conflict of interest that the insurer has relating to any assessment or examination to which the application relates.

(8) A notice required under subsection (6) may be given verbally if, as soon as practicable afterwards, written confirmation of the notice is given to every person who received verbal notice.

(4) Subsection 38.2 (13) of the Regulation is revoked and the following substituted:

(13) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination with respect to the application to the insured person and the person who prepared the application.

(13.1) The determination of the insurer shall specify the assessments or examinations the insurer agrees to pay for, the assessments or examinations the insurer refuses to pay for and the reasons for the insurer’s decision.

(13.2) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may make a determination that the insured person is not entitled to the expenses to which the examination relates.

(13.3) If an insured person subsequently complies with subsection 42 (10), the insurer shall reconsider the application and make a determination under this section.

(13.4) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the application by the day determined in the following manner, the insurer shall pay for all assessments and examinations to which the application relates:

1. If the attendance of the insured person was not required for the examination under section 42, the day is the 10th business day after the day the material required under subsection 42 (10) was provided.

2. If the attendance of the insured person was required for the examination, the day is the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed.

(13.5) An insurer shall pay for all assessments and examinations that it has agreed to pay for or that it is required under this section to pay for within 30 days after receiving an invoice for the cost of the assessment or examination.

17. Section 39 of the Regulation is revoked and the following substituted:

Attendant Care Benefits

39. (1) An application for attendant care benefits for an insured person must be in the form of an assessment of attendant care needs for the insured person that is prepared and submitted to the insurer by a member of a health profession who is authorized by law to treat the person’s impairment.

(2) Within 10 business days after receiving the assessment of attendant care needs, the insurer shall give the insured person a notice that,

(a) advises the insured person which, if any, expenses described in the assessment of attendant care needs the insurer agrees to pay; and

(b) advises the insured person that the insurer requires the insured person to be examined under section 42, if the insurer has not agreed to pay all expenses described in the assessment of attendant care needs.

(3) An insurer may, but is not required to, pay an expense incurred before an assessment of attendant needs that complies with subsection (1) is submitted to the insurer.

(4) The insurer shall begin payment of attendant care benefits within 10 business days after receiving the assessment of attendant care needs and, pending receipt by the insurer of the report of any examination under section 42 required by the insurer, shall calculate the amount of the benefits based on the assessment of attendant care needs. 

(5) If an insurer wants to determine if an insured person is still entitled to attendant care benefits, wants to determine if the benefits are being paid in the appropriate amount or wants to determine both, the insurer shall give the person a notice requesting that a new assessment of attendant care needs for the insured person that complies with subsection (1) be submitted to the insurer within 10 business days after the insured person receives the notice.

(6) Subject to subsection (10), a notice under subsection (5) may also advise the insured person that the insurer requires the insured person to be examined under section 42. 

(7) Subject to subsection (10), new assessments of attendant care needs may be submitted to an insurer at any time there are changes that would affect the amount of the benefits.

(8) If a new assessment of attendant care needs indicates that it is appropriate to increase the amount of the attendant care benefits and the insurer has not already advised the insured person that the insurer requires the insured person to be examined under section 42, the insurer may give a notice to the insured person advising that the insurer requires the insured person to be examined under section 42.

(9) If a new assessment of attendant care needs is required under subsection (5) or the insurer requires an examination under section 42, the insurer shall, subject to section 18, continue to pay the insured person attendant care benefits at the same rate until the insurer receives the assessment of attendant care needs or the report of the examination, as applicable. 

(10) If more than 104 weeks have elapsed since the accident, the insurer shall not require the insured person to be examined under section 42 to determine the insured person’s entitlement to attendant care benefits and the insured person shall not submit nor be required to submit an assessment of attendant care needs to the insurer unless,

(a) the insured person is or may be entitled under section 18 to receive attendant care benefits more than 104 weeks after the accident; and

(b) at least 52 weeks have elapsed since the last examination under section 42.

(11) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination with respect to the benefit to the insured person and to the member of the health profession who prepared the assessment of attendant care needs.

(12) The insurer’s determination shall specify the benefits and expenses the insurer agrees to pay, the benefits and expenses the insurer refuses to pay and the reasons for the insurer’s decision.

(13) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may,

(a) make a determination that the insured person is not entitled to attendant care benefits; and

(b) refuse to pay attendant care benefits relating to the period after the person failed or refused to comply with subsection 42 (10) and before the insured person submits to the examination and provides the material required by subsection 42 (10).

(14) If an insured person subsequently complies with subsection 42 (10), the insurer shall,

(a) reconsider the application and make a determination under this section;

(b) subject to the new determination, resume payment of attendant care benefits; and

(c) pay all amounts, if any, that were withheld during the period of non-compliance, if the insured person provides not later than the 10th business day after the failure or refusal to comply, or as soon as practicable after that day, a reasonable explanation for not complying with subsection 42 (10).

(15) If an insurer determines that an insured person is not entitled, by reason of section 18, to attendant care benefits for expenses incurred more than 104 weeks after the accident, the insurer shall give the insured person a notice of its determination, with reasons, not less than 10 business days before the last payment of attendant care benefits.

(16) An assessment of attendant care needs under this section in respect of accidents occurring on or after March 1, 2006 shall be in the form of and contain the information required in the “Assessment of Attendant Care Needs” dated December 31, 2005 and available on the website http://www.fsco.gov.on.ca/.

(17) An assessment of attendant care needs under this section in respect of accidents occurring before March 1, 2006 shall be in Form 1, as it read on February 28, 2006.

18. Subsections 40 (2), (3), (3.1) and (4) of the Regulation are revoked and the following substituted:

(2) Within 30 days after receiving an application under subsection (1), the insurer shall give the insured person,

(a) a notice stating that the insurer has determined that the impairment is a catastrophic impairment; or

(b) a notice advising the insured person that the insurer requires the insured person to be examined under section 42 to assist the insurer in determining if the impairment is a catastrophic impairment.

(3) If an application is made under this section not more than 104 weeks after the accident and, immediately before the application was made, the insured person was receiving attendant care benefits,

(a) the insurer shall continue to pay attendant care benefits to the insured person during the period before the insurer makes a determination under this section; and

(b) the amount of the attendant care benefits for the period referred to in clause (a) shall be determined on the assumption that the insured person’s impairment is a catastrophic impairment.

(4) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination of whether the insured person’s impairment is a catastrophic impairment to the insured person and to the health practitioner who prepared the application under this section.

(5) The determination of the insurer shall specify the reasons for the insurer’s determination of whether the insured person’s impairment is a catastrophic impairment.

(6) If an insured person fails or refuses to comply with subsection 42 (10), the insurer,

(a) may make a determination that the insured person does not have a catastrophic impairment;

(b) may stop payment of any benefits that are payable only if the insured person has a catastrophic impairment; and

(c) may, in respect of the period after the insured person failed or refused to comply with subsection 42 (10) and before the insured person submits to the examination and provides the material required by subsection 42 (10), refuse to pay a benefit or expense that is payable only if the person has a catastrophic impairment.

(7) If an insured person subsequently complies with subsection 42 (10), the insurer shall,

(a) reconsider the application and make a determination under this section;

(b) subject to the determination, resume payment of benefits, if benefits were being paid before the examination; and

(c) pay all amounts, if any, that were withheld during the period of non-compliance, if the insurer determines that the insured person sustained a catastrophic impairment and the insured person provides not later than the 10th business day after the failure or refusal to comply, or as soon as practicable after that day, a reasonable explanation for not complying with subsection 42 (10).

(8) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the application by the day determined in the following manner, the insurer shall, for the period commencing on that day and ending on the day the insurer gives the insured person the report or determination, pay all amounts in respect of benefits and goods and services to which the insured person would be entitled if he or she had sustained a catastrophic impairment:

1. If the attendance of the insured person was not required for the examination under section 42, the day is the 15th business day after the day the material required under subsection 42 (10) was provided.

2. If the attendance of the insured person was required for the examination, the day is the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed.

19. Section 41 of the Regulation is amended by adding the following subsection:

(3) In the case of a benefit described in section 22, subsections (1) and (2) are subject to sections 35 and 37.

20. The Regulation is amended by adding the following section:

Transitional Rules — March 1, 2006

41.1 (1) Subject to subsection (2), sections 34, 35 and 37, as they read on February 28, 2006, continue to apply in respect of a claim by a person for income replacement, non-earner or caregiver benefits if, under subsection 37 (1), as it read on February 28, 2006, the insurer gave or was required to give the person, before March 1, 2006, a notice with respect to the claim.

(2) If, after February 28, 2006, an insurer wishes to determine if a person continues to be entitled to receive income replacement, non-earner or caregiver benefits, section 37, as it reads after February 28, 2006 applies.

(3) Subsections 37.2 (2) to (5), as they read on February 28, 2006, continue to apply in respect of a claim by an insured person for ancillary goods or services if, under subsection 37.1 (5) as it read on February 28, 2006, the insurer gave or was required to give the insured person, before March 1, 2006, a notice under section 37.1 as it read on February 28, 2006, stating that the insurer requires the insured person to be assessed by a designated assessment centre in respect of ancillary goods or services for which the insurer will not pay.

(4) Section 38, as it read on February 28, 2006, continues to apply in respect of a claim for medical and rehabilitation benefits by an insured person if, under subsection 38 (8.1) as it read on February 28, 2006, the insurer gave or was required to give the insured person, before March 1, 2006, a notice referred to in subclause 38 (12) (b) (ii) or (12.1) (b) (ii), as it read on February 28, 2006.

(5) If, before March 1, 2006, an insured person has submitted an application under subsection 38 (3.1), as it read on February 28, 2006, subsection 38 (18) as it read on that day continues to apply in respect of the application.

(6) Subsections 38.2 (8) and (13), as they read on February 28, 2006, and subsections 38.2 (9) to (12) and (14) to (16) apply in respect of an application for approval for an assessment or examination if, under subsection 38.2 (6), as it read on February 28, 2006, the insurer gave or was required to give the insured person, before March 1, 2006, a notice under subsection 38.2 (6), as it read on February 28, 2006, requiring the insured person to be assessed by a designated assessment centre.

(7) Section 39, as it read on February 28, 2006, continues to apply to an application for attendant care benefits by an insured person if, under subsection 39 (4), as it read on February 28, 2006, the insurer gave or was required to give the insured person, before March 1, 2006, a notice under subsection 39 (4), as it read on February 28, 2006, requiring the insured person to be assessed by a designated assessment centre.

(8) Section 39, as it read on February 28, 2006, continues to apply to an application for an increase in attendant care benefits if, under subsection 39 (7) or (8), as it read on February 28, 2006, an insurer gave or was required to give the insured person, before March 1, 2006, a notice requiring the insured person to be assessed by a designated assessment centre.

(9) Section 40, as it read on February 28, 2006, continues to apply to an application for a determination of whether an insured person has a catastrophic impairment if, under subsection 40 (2), as it read on February 28, 2006, the insurer gave or was required to give the insured person, before March 1, 2006, a notice under subsection 40 (2), as it read on February 28, 2006, requiring the insured person to be assessed by a designated assessment centre.

(10) Despite subsections (1) to (9), if a designated assessment of an insured person cannot be conducted or completed on or after March 1, 2006 because there is no designated assessment centre that satisfies the requirements of section 53, the insurer may give the insured person notice under subsection 42 (4), as it reads after February 28, 2006, requiring the insured person to be examined under section 42 in respect of the claim or application, instead of being assessed by a designated assessment centre, and the provisions of this Regulation, as they read after February 28, 2006, apply in respect of the disposition of the claim or application after the notice is given.

21. Section 42 of the Regulation is revoked and the following substituted:

Examination Required by Insurer

42. (1) For the purposes of assisting an insurer determine if an insured person is or continues to be entitled to a benefit under this Regulation for which an application is made, an insurer may, as often as is reasonably necessary, require an insured person to be examined under this section by one or more persons chosen by the insurer who are members of a health profession or are social workers or who have expertise in vocational rehabilitation.

(2) Subsection (1) does not apply with respect to,

(a) a benefit to which section 37.1 applies, other than an amount claimed for ancillary goods or services referred to in section 37.2; or

(b) a funeral benefit or death benefit.

(3) Subject to subsection (7), each of the following examinations under this section shall be limited to an examination of material provided under subsection (10) in respect of the insured person without requiring the attendance of the insured person:

1. An examination for the purposes of section 37.2 to assist the insurer in determining whether to pay for ancillary goods or services claimed by the insured person.

2. An examination after an application is made under section 38 to assist the insurer in determining if the insured person has an impairment to which a Pre-approved Framework Guideline applies.

3. An examination for the purposes of section 38 to assist the insurer in determining whether to pay for goods or services contemplated by a treatment plan if the goods and services are substantially similar to goods or services the insurer previously refused to pay for when they were included in a previous treatment plan submitted to the insurer on behalf of the insured person in respect of the same accident.

4. An examination for the purposes of section 38.2 relating to an application for approval of an assessment or examination.

5. An examination for the purposes of section 40 that relates only to the issue of whether the insured person has a brain impairment that results in a score of 9 or less on the Glasgow Coma Scale referred to in subclause 2 (1.2) (e) (i).

(4) Whenever the insurer requires an insured person to be examined under this section, the insurer shall arrange for the examination at its expense and shall give the insured person a notice setting out,

(a) the reasons for the examination;

(b) the type of examination that will be conducted and whether the attendance of the insured person is required during the examination;

(c) the name of the person or persons who will conduct the examination, the regulated health professions to which they belong and their titles and designations indicating their specialization, if any, in their professions; and

(d) if the attendance of the insured person is required at the examination, the day, time and location of the examination and, if the examination will require more than one day, the same information for the subsequent days.

(5) If the insurer has already notified the insured person under this Regulation that the insurer requires the insured person to be examined under this section, the insurer shall give the notice required under subsection (4),

(a) not more than two business days after the previous notice was given, if the attendance of the insured person is not required at the examination, unless the examination is for the purposes of assisting the insurer determine if the insured person has a catastrophic impairment; or

(b) not more than five business days after the previous notice was given and, unless the insured person and the insurer mutually agree otherwise, not less than five business days before the examination, if the attendance of the insured person is required at the examination or if the examination is for the purposes of assisting the insurer determine if the insured person has a catastrophic impairment.

(6) If the insurer is not authorized under another section of this Regulation to give the insured person notice that the insurer requires the insured person to be examined under this section, the insurer shall give the insured person the notice required under subsection (4) not less than five business days before the examination, unless the insured person and insurer mutually agree otherwise.

(7) If a notice under subsection (4) indicates that the attendance of the insured person is not required for the examination and it is subsequently determined by the person conducting the examination that the insured person should be in attendance and personally examined, the insurer shall give a notice to the insured person within two business days after the day the notice described in subsection (4) is given and at least five business days before the examination,

(a) notifying the insured person of the change in the type of examination;

(b) requiring the attendance of the insured person at the examination; and

(c) setting out the day, time and location of the examination and, if the examination will require more than one day, setting out the same information for the subsequent days.

(8) A notice under subsection (4) or (7) may be verbal if a written confirmation is given as soon as practicable afterwards.

(9) The following applies if the attendance of the insured person is required at an examination:

1. The insurer shall make reasonable efforts to schedule the examination for a day and time that are convenient for the insured person.

2. Subject to paragraph 3, the examination must be conducted, unless the insured person otherwise consents, at a location that is not more than,

i. 30 kilometres from the insured person’s residence, if the residence is in the City of Toronto or in The Regional Municipality of Durham, The Regional Municipality of Halton, The Regional Municipality of Peel or The Regional Municipality of York, or

ii. 50 kilometres from the insured person’s residence, if the residence is not in a municipality described in subparagraph i.

3. If, after taking reasonable steps, the insurer is unable to arrange for a qualified person to conduct the examination at a location within the distance required under subparagraph 2 i or ii, as applicable, the insurer may arrange for the examination to be conducted by a qualified person at a location that is reasonable in the circumstances.

(10) For the purposes of the examination,

(a) the insured person and the insurer shall, within five business days after the day the notice of the examination under subsection (4) or (7) is received by the insured person, provide to the person or persons conducting the examination all reasonably available information and documents that are relevant or necessary for the review of the insured person’s medical condition; and

(b) if the attendance of the insured person is required at the examination, the insured person shall attend the examination and submit to all reasonable physical, psychological, mental and functional examinations requested by the person or persons conducting the examination.

(11) Subject to subsection (12), if the insured person complies with subsection (10), the person or persons conducting the examination shall complete the examination, prepare a report of their findings and provide a copy of the report to the insurer in accordance with the following:

1. If the attendance of the insured person was not required for the examination, the examination must be completed and a copy of the report provided to the insurer,

i. not more than 10 business days after the day the notice of the examination under subsection (4) was given to the insured person, if the examination relates to whether the insured person has a catastrophic impairment, or

ii. not more than five business days after the day the notice of the examination under subsection (4) was given to the insured person, in any other case.

2. If the attendance of the insured person was required at the examination and the examination relates to whether the insured person has sustained a catastrophic impairment or, if the insured person has sustained a catastrophic impairment, relates to whether the insured person is entitled to medical benefits, rehabilitation benefits, specified benefits under section 35 or attendant care benefits,

i. the examination must be completed not more than 30 business days after the day the notice relating to the examination was given under subsection (4) or, if a notice was given under subsection (7), 30 business days after the day that notice was given, and

ii. a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed.

3. If the attendance of the insured person was required at the examination and paragraph 2 does not apply,

i. the examination must be completed not more than 10 business days after the day the notice relating to the examination was given under subsection (4) or, if a notice was given under subsection (7), 10 business days after the day that notice was given, and

ii. a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed.

(12) If an insured person who failed or refused to comply with subsection (10) subsequently complies, the following rules apply:

1. If the attendance of the insured person was not required for the examination, the examination must be completed and a copy of the report provided to the insurer,

i. not more than 10 business days after the day the material required under subsection (10) was provided, if the examination relates to whether the insured person has a catastrophic impairment, or

ii. not more than five business days after the day the material required under subsection (10) was provided in any other case.

2. If the attendance of the insured person was required for the examination, a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed.

(13) If the examination relates to a claim for attendant care benefits, the report of the examination must include an assessment of attendant care needs.

Assessment or Examination after Denial of Benefits

42.1 (1) In this section,

“original provider” means, in respect of an insured person, the member of a health profession who, in accordance with this Regulation, approved the treatment plan, prepared the assessment of attendant care needs, completed the disability certificate or prepared the application under section 40, as applicable, that was submitted to the insurer with respect to the insured person.

(2) This section applies in respect of an insured person if the following conditions are satisfied:

1. An examination of the insured person was conducted under section 42 and the insurer gave to the insured person a copy of the report of the examination and the insurer’s determination.

2. The insurer’s determination is,

i. that the insured person is not entitled to benefits, if the examination related to a claim for benefits, or

ii. that the insured person does not have a catastrophic impairment, if the examination related to an application under section 40.

3. The examination under section 42 was not related to, 

i. a claim for ancillary goods or services referred to in section 37.2, or

ii. an application under section 38.2 for approval for an assessment or examination.

4. The examination under section 42 was not for the purposes of assisting the insurer determine if the insured person has an impairment to which a Pre-approved Framework Guideline applies.

5. If the examination under section 42 related to a claim for a specified benefit under section 35, no assessment or examination relating to that benefit has been conducted previously under this section.

6. If the examination under section 42 related to a claim for an attendant care benefits under section 39, no assessment or examination relating to that benefit has been conducted under this section within the previous 12 months.

7. The examination under section 42 was not an examination to which subsection 42 (6) applied.

(3) The insurer shall pay fees in accordance with this section for an assessment or examination of the insured person and for the preparation of a report of the assessment or examination if the following conditions are satisfied:

1. The assessment or examination and the report of the assessment or examination are limited to the portions of the report of the examination under section 42 with which the insured person does not agree and that are relevant to the denial of the claim or application.

2. The assessment or examination is conducted by one or more members of a health profession who are authorized under this section to conduct the assessment or examination.

3. If the insured person has sustained a catastrophic impairment or the examination under section 42 relates to whether the insured person has sustained a catastrophic impairment, the assessment or examination under this section is conducted and the report provided to the insurer not more than 80 business days after the day the insurer gave the insured person notice of its determination.

4. If the insured person has not sustained a catastrophic impairment and the examination under section 42 does not relate to whether the insured person has sustained a catastrophic impairment, the assessment or examination is conducted and the report is provided to the insurer not more than 40 business days after the day the insurer gave the insured person notice of its determination.

(4) Subject to paragraph 2 of subsection (3) and subsections (5) and (6), an assessment or examination under this section must be conducted by the original provider or, if the insured person had more than one original provider, the original provider designated by the insured person.

(5) The assessment or examination under this section may be conducted by any person who is a member of any health profession if,

(a) the original provider is not a member of the same health profession as the person who conducted the examination under section 42; or

(b) the original provider is a member of the same health profession as the person who conducted the examination under section 42, but is not legally authorized to practise in the same specialty.

(6) If members of two or more health professions conducted the examination under section 42, the assessment or examination under this section may be conducted by one or more persons other than the original provider.

(7) The assessment or examination under this section shall be limited to an examination of the material provided under subsection 42 (10) to the person who conducted the examination under section 42 if,

(a) the examination under section 42 was conducted by a person who,

(i) is a member of the same health profession as the original provider, and

(ii) is legally authorized to practise in the same specialty as the original provider, if the original provider is legally authorized to practise in a specialty;

(b) the examination under section 42 was limited to an examination of the material provided under subsection 42 (10) to the person who conducted that examination; or

(c) the assessment or examination relates to a claim for medical benefits or rehabilitation benefits and an assessment or examination of the insured person with respect to the same accident has been conducted under this section within the previous 12 months.

(8) If the insured person does not have a catastrophic impairment and the assessment or examination under this section does not relate to whether the insured person has a catastrophic impairment, the total amount payable for an assessment or examination under this section, for the preparation of the report of the assessment or examination and for any related expenses permitted under section 24 shall not exceed the amount determined as follows:

1. If the assessment or examination is limited to, or required by this section to be limited to, an examination of the material provided under subsection 42 (10), the maximum amount payable is $450.

2. If the assessment or examination is not limited to nor required by this section to be limited to an examination of the material provided under subsection 42 (10), the maximum amount payable is,

i. $900 if the assessment or examination is conducted by one or more members of a health profession and at least one of them is a physician who is legally authorized to practise in a medical specialty other than family medicine, or

ii. $775 if the assessment or examination is conducted by one or more members of a health profession and none of them are physicians described in subparagraph i.

(9) Amounts payable under this section shall be paid by the insurer within 30 days after receipt of an invoice for the amounts.

(10) An assessment or examination under this section shall be used only for the purposes of assisting in the resolution of a dispute in accordance with sections 280 to 283 of the Act and the insurer is not required as a result of receiving the report of the assessment or examination to allow any application or pay any benefit that it otherwise would not have allowed or paid.

22. Clause 43 (13) (a) of the Regulation is amended by striking out “in Form 1”.

23. Clauses 47 (1) (d) and (e) of the Regulation are revoked and the following substituted:

(d) if, by reason of subsection 41.1 (1), subsection 37 (4), as it read on February 28, 2006, applies, any income replacement benefits, non-earner or caregiver benefits that is paid for the period after the insurer gave notice under subsection 37 (1), as it read on that date, and before the date of the report of the designated assessment centre; or

(e) fees paid by the insurer that are referred to in paragraph 8 of subsection 24 (1) if the insured person fails, without a reasonable explanation, to attend a designated assessment that has been arranged, or cancels a designated assessment without providing such notice as may be specified in the Pre-assessment Cancellation Fee Schedule established by the committee referred to in section 52, as it may be amended from time to time, that he or she will not be attending the designated assessment.

24. Section 50 of the Regulation is revoked and the following substituted:

Mediation Proceedings

50. An insured person shall not commence a mediation proceeding under section 280 of the Act unless,

(a) the insured person notified the insurer of the circumstances giving rise to a claim for a benefit and submitted an application for the benefit within the times prescribed by this Regulation; and

(b) the insured person, if he or she was required to undergo a designated assessment under section 43, has undergone the designated assessment and has complied with that section.

25. Clause 52 (a) of the Regulation is revoked. 

26. Subsection 55 (5) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

27. Subsection 56 (4) of the Regulation is amended by striking out “14 days” and substituting “10 business days”.

28. (1) Subsection 68 (1) of the Regulation is revoked and the following substituted:

(1) Except as otherwise permitted by this Regulation, all notices required or permitted under this Regulation, other than a notice under subsection 32 (1) or (3.1), shall be in writing.

(2) Section 68 of the Regulation is amended by adding the following subsections:

(2.1) For the purposes of clauses (2) (a) and (b), an authorized representative may include, subject to subsection (2.2),

(a) a member of a health profession if the document is a notice under subsection 38 (5) or (8), 38.2 (4) or (6) or 42 (4) or a report prepared under section 42; or

(b) a member of a health profession who is a health practitioner if the document is a notice under subsection 37.1 (4) or (5).

(2.2) Subsection (2.1) does not apply unless,

(a) the insured person is not represented at the relevant time by a solicitor or another authorized representative;

(b) the insured person gives to the insurer a signed authorization and direction specifying which documents listed in subsection (2.1) that the insurer is authorized and directed to give to the member of the health profession;

(c) the signed authorization and direction is given to the insurer before the document is given to the member of the health profession; and

(d) the member of the health profession has agreed to act in accordance with the authorization and direction.

. . . . .

(13) A member of a health profession who receives a document under the authority of subsection (2.1) shall immediately notify the insured person by telephone of the substance of the document and send a copy of the document to the insured person by ordinary mail or fax.

(14) An insurer shall not deliver documents to a member of a health profession in reliance on an authorization under subsection (2.2) unless the documents are expressly specified in the authorization referred to in that subsection.

29. The Regulation is amended by adding the following section:

Substitute Decision-makers

68.1 Any consent, notice or other thing to be given by or to an insured person under this Regulation may be given by or to a person exercising a power of decision on behalf of the insured person under the authority of the Substitute Decisions Act, 1992 or as authorized under the Health Care Consent Act, 1996

30. (1) Paragraph 2 of section 69 of the Regulation is revoked and the following substituted:

2. A disability certificate.

2.1 A consent under section 32.1.

2.2 A notice under subsection 35 (3) or (4).

(2) Paragraph 4 of section 69 of the Regulation is revoked and the following substituted:

4. A notice under subsection 37.1 (5).

(3) Section 69 of the Regulation is amended by adding the following paragraphs:

5.1 A notice under subsection 37.2 (2).

. . . . .

6.1 A notice under subsection 38 (8).

. . . . .

7.1 A notice under subsection 38.2 (6).

7.2 A notice under section 39 advising an insured person that the insurer requires him or her to be examined under section 42.

. . . . .

10.1 A notice under section 42.

31. Form 1 of the Regulation is revoked.

32. This Regulation comes into force on March 1, 2006. 

 

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